Patient Safety Watch: Trend of police investigations has profound consequences

Good afternoon and welcome to the latest edition of the Patient Safety Watch newsletter.

Corporate manslaughter probe launched into Nottingham maternity failings

As reported by The i Paper, Nottingham University Hospitals Trust is now at the centre of a criminal investigation into serious and longstanding failings in its maternity services. The investigation — Operation Perth — is being conducted by Nottinghamshire Police, who will assess whether the trust’s actions amounted to gross negligence at an organisational level.

The trust is already under the scrutiny of a major independent review led by Donna Ockenden, which is examining around 2,500 cases of stillbirth, neonatal death, and maternal harm at Queen’s Medical Centre and Nottingham City Hospital over more than a decade.

Detective superintendent Matthew Croome confirmed that police are investigating a “serious criminal offence” and are seeking to establish where overall responsibility lies.

A group representing affected families described the news as bringing “mixed emotions”, noting that their repeated warnings were ignored for years. As one statement put it: “No investigation will ever reverse the harm… but families are feeling an immense sense of vindication.”

In response, NUH chair Nick Carver and chief executive Anthony May said: “It is absolutely right that we take accountability – we are deeply sorry for the pain and suffering caused.”

Castle Hill Hospital heart surgery deaths under police investigation

Humberside Police has also opened an investigation into avoidable patient deaths following transcatheter aortic valve implantation (TAVI) procedures at Castle Hill Hospital, near Hull.

According to documents obtained by the BBC, at least 11 TAVI cases between 2019 and 2023 involved serious clinical failings, including misleading death certificates and avoidable harm. One case involved Dorothy Readhead, who died after a six-hour procedure under local anaesthesia, during which she lost five litres of blood; yet the failed surgery was not mentioned on her death certificate.

A 2024 Royal College of Physicians review cited not only poor clinical care but also a lack of transparency, with a mortality rate nearly three times the national average during the review period.

Hull University Teaching Hospitals Trust stated it has since implemented all RCP recommendations and maintains confidence in its cardiac services. Police enquiries remain ongoing, and no arrests have been made at this time.

Wider national pattern

The first two stories in this edition are part of a wider national pattern. Other NHS trusts – including Leicestershire Partnership Trust, Royal Sussex County Hospital and Shrewsbury and Telford Hospital Trust are also currently under police investigation.

As someone who lived through a four-year police investigation into the preventable death of my own son (2011–2015), I know firsthand the profound emotional toll these processes take – and the far-reaching consequences for everyone involved. The long wait for answers, the legalistic lens of criminal law, with its high thresholds for prosecution, often feels far removed from the level at which true accountability should rest. And all of this unfolds at a time when what is most needed is openness, reflection, and improvement.

Too often, accountability in the NHS feels fragmented, delayed – or absent altogether. It’s hard not to conclude that the current system is fundamentally broken. The government is now considering proposals to regulate NHS managers – an action that many will see as not only necessary, but long overdue.

In other news this edition…

Coroner appeals for families of Ian Paterson’s patients

A judge-led inquest into the deaths of patients treated by jailed surgeon Ian Paterson has issued a public appeal to help trace the families of five women whose cases are under review.

As reported by the BBC, coroner judge Richard Foster is seeking next of kin for five former patients of Paterson, who is serving a 20-year sentence for carrying out unnecessary and harmful surgeries.

Renaming physician associates to reduce risk and confusion

As reported by The Telegraph this week, a government-commissioned review, led by Professor Gillian Leng, is expected to recommend renaming physician associates (PAs) in the NHS, following concerns that patients may confuse them with fully qualified doctors. Suggested alternatives include “physician assistants” or “doctor’s assistants”.

The review was prompted by serious safety concerns, including misdiagnoses and avoidable deaths. Focus groups have found widespread confusion, which risks eroding trust and compromising care.

Health and social care secretary Wes Streeting is expected to adopt the recommendation once the review is published in June.

New law protects nurse title

As of 12 May 2025, it is now a criminal offence in the UK for anyone to falsely claim to be a nurse without registration with the Nursing and Midwifery Council. The law aims to protect patients and uphold professional standards.

Chief nursing officer Duncan Burton welcomed the move as a key step toward restoring public trust and safeguarding care quality.

Dementia care failures highlight patient safety risks

The Care Quality Commission’s new dementia strategy raises serious concerns about the safety and quality of care for people living with dementia in England.

Key findings include:

• Diagnosis delays averaging 151 days, with stark regional disparities;
• Understaffing in care homes with high dementia needs;
• Reports of neglect, including dehydration, soiling, and unsafe discharges;
• Environments not tailored to support dementia patients in hospitals and care homes.

The CQC is calling for national standards and mandatory dementia training. While examples of good care exist, the report stresses the need for system-wide improvement to ensure safety and dignity for all.

£750m to tackle crumbling NHS buildings

The government has pledged £750m to address urgent infrastructure issues across NHS hospitals – including repairs to operating theatres, mental health units, and emergency departments.

Mr Streeting said: “Patients and staff deserve to be in buildings that are safe, comfortable, and fit for purpose. Through our Plan for Change, we will make our NHS fit for the future.”

NHS staff should not be given police powers, say royal colleges

As reported by The Independent, a coalition of professional bodies has urged the government to rethink plans to give NHS staff police-like powers to detain individuals during mental health crises.

The Royal College of Psychiatrists, the Royal College of Nursing, and the British Medical Association argue that the move risks harming staff, confusing legal responsibilities, and damaging patient trust. These are policing duties – not medical ones.

Sharing some good stuff…

Blog highlight: Prioritising Patient Safety

In the latest edition of Prioritising Patient Safety, Tony Dysart, senior lead clinician at the Parliamentary and Health Service Ombudsman, explores how NHS complaints are helping drive real improvements in care – from safer imaging practices to better palliative care training.

Find out how NHS England is responding to concerns around diagnostic imaging, how trusts are using feedback to make meaningful change, and what new national guidance is shaping the future of patient safety.

Maternity safety – a must-attend moment this September

Those interested in maternity safety will already know that Baby Lifeline’s annual National Maternity Safety Conference is a must-attend event – and this year’s programme is shaping up to be the most powerful yet.

With key voices including Donna Ockenden, Dr Bill Kirkup, Dr Penny Dash, and Gill Walton, the conference will focus on the most pressing challenges in maternity care today – from equity and safety to workforce wellbeing and innovation.

Taking place on 25 September 2025 in Birmingham, this is a vital opportunity to come together, share learning, and help shape the future of maternity services.

Read the latest blog from Baby Lifeline’s CEO, Judy Ledger MBE, to find out more about why this year matters so much – and how to book your place.

Help us improve patient safety across NHS hospitals – share your experiences!

One common frustration in patient safety improvement is that efforts often happen in isolation. This can lead to duplicated work, missed chances to learn from successful solutions elsewhere, and inconsistent approaches across the system.

That’s why Patient Safety Watch is leading a vital project to gather insights directly from those who have designed or implemented patient safety interventions in NHS hospitals. We want to understand what’s being done, how interventions were developed, and how effective they have been – especially in tackling three key patient safety risks:

• Falls prevention
• Pressure ulcers
• Medication safety during transitions of care (such as moving patients from accident and emergency to wards)

Whether you’ve led a project, contributed to an initiative, or worked on activities aimed at improving inpatient care in these areas, your input is invaluable.

Take our short survey to help us capture what’s working and share learnings that can benefit hospitals everywhere.

Don’t miss out on the chance to present at Patient Safety Congress!

Last week to submit your entry to the HSJ Patient Safety Improvement Competition 2025.

Have a project that’s making patient care safer? Showcase your work at the HSJ Patient Safety Congress – Honest Conversations: Putting Safety at the Heart of Reform (15 to16 September 2025, Manchester Central Convention Centre).

Ten category winners will be invited to present lightning talks in the Innovation Spotlight Theatre, with one overall winner announced at the event.

Deadline: 5pm on Friday 13 June.

Download the entry template and apply now!

Any questions: Please reach out to James.elliot@hsj.co.uk

That’s all for this edition. Thanks for reading. Look out for our next patient safety roundup from Jeremy in two weeks’ time.

James Titcombe